Fluoro-2-deoxy-d-glucose-positron emission tomography (FDG-PET) is utilized in more than 90% of cancers in staging, re-staging, assessing therapy response and during the follow-up. However, not all tumors show significant increase of metabolic activity on FDG-PET imaging. This is particularly true for prostate cancer, neuroendocrine tumors and hepatic tumors. In this review we have considered those already used for clinical applications such as 11C- and 18F-Choline, 11C-Methionine and 18F-FET, 18F-DOPA, 68Ga-DOTA-somatostatine analogues, 11C-Acetate and 18F-FLT. Choline presents a high affinity for malignant prostate tissue, even if low grade. Choline can be labeled with either 11C or 18F, the former being the preference due to lower urinary excretion and patients exposure. The latter is more useful for possible distribution to centers lacking in on-site cyclotron. Methionine is needed for protein synthesis and tumor cells require an external supply of methionine. These tracers have primarily been used for imaging of CNS neoplasms. The most appropriate indication is when conventional imaging procedures do not distinguish between edema, fibrosis or necrosis and disease relapse. In addition, the uptake of 11C-Methionine is proportional to the tumor grade and, therefore, the maximum small unilamellar vesicles (SUV) inside the brain mass before therapy is somehow considered a prognostic value. Neuroendocrine tumors (carcinoids, pheocromocytoma, neuroblastoma, medullary thyroid cancer, microcytoma, carotid glomus tumors, and melanoma) demonstrate an increased activity of L-DOPA decarboxylase, and hence they show a high uptake of 18FDOPA. For the study of NETs, 68Ga-DOTA-TOC/DOTA-NOC has been introduced as PET tracer. This compound for PET imaging has a high affinity for sst2 and sst5 and has been used in the detection of NETs in preliminary studies; 68Ga-DOTA-NOC PET is useful before metabolic radiotherapy in order to evaluate the biodistribution of the therapeutic compound; 18F-FLT is a specific marker of cell proliferation and the most important field of application of FLT is lung cancer. Other tracers are used in PET utilized as markers of hypoxia inside big neoplastic masses include 18F-MISO, 64Cu-ATSM, 18F-EF5, which highlight the presence of hypoxic areas are useful for patients that must be treated with radiotherapy.

Molecular imaging using 18F-fluoro-deoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) has been successfully used in the diagnosis, initial staging, and response assessment of various malignant tumors. Advances in radiation therapy planning and delivery have ushered in the era of high-precision conformal radiotherapy allowing generation of dose distributions that conform closely to the shape of the target volume while minimizing high-dose regions in the surrounding normal tissues. Traditionally, radiation therapy planning has relied heavily on CT imaging, but recent times have witnessed tremendous enthusiasm for the use of PET/CT-guidance in radiotherapy planning. This has been largely stimulated by widespread availability and integration with treatment planning systems. However, several issues need to be addressed and challenges overcome to realize the full potential of this exciting technology. Integrating PET/CT fusion imaging into routine clinical practice can be challenging due to technical, administrative, financial, geographic, and personnel issues. Concerted efforts are urgently needed for the development of guidelines for appropriate application of this technology using standardized methodology. There is accumulating evidence that incorporating PET/CT imaging in radiotherapy planning for lung cancer, head and neck cancer and cervical cancer has a significant impact. This review highlights the promises and pitfalls of PET/CT imaging in radiotherapy treatment planning with a critical appraisal of the current best evidence for its application in the modern radiotherapy clinic, and provides a sneak preview into the future of such technology.

Positron emission computed tomography (PET) is a functional diagnostic imaging technique, which can accurately measure in vivo distribution of a variety of radiopharmaceuticals. The ability of PET to study various biological processes (glucose, amino acid, phospholipids, receptors etc.) opens up new possibilities for both day-to-day clinical use and research applications in the practice of oncology. Addition of CT to PET has resulted in better specificity and sensitivity than either of the modalities alone, as the combined approach has the ability to demonstrate functional and structural details in the same setting. F-18 fluoro-2-deoxy-D-glucose (FDG), an analogue of glucose, is the most commonly used radiotracer in PET-CT imaging. The F-18 FDG uptake in tumor cells is directly proportional to glucose metabolism in the cells. Since glucose metabolism is increased several folds in the malignant tumors, PET-CT images show preferential higher FDG uptake in malignant cells as compared to normal cells. F-18 FDG PET-CT has been found to be useful in the initial staging, detection of recurrent disease and monitoring the response to the therapy in malignancies including lung cancer, colorectal cancer, lymphoma, melanoma, esophageal cancer, head and neck cancer, breast cancer.

Background : An intriguing aspect of Oral Squamous Cell Carcinomas (OSCC) is its behavioral disparity. Among patients who present with the similar clinicopathological features, some have a better prognosis than others. Identification of molecular alterations responsible for this may contribute to a greater understanding of tumor behavior. Tissue microarray (TMA) approach is a high throughput technology that enables analysis of multiple molecular targets simultaneously without causing any morphological alteration to tissue specimens. Aim and Objective : To assess the tumor behavior based on the expression of p53, Bcl-2 and E-cadherin using TMA technology. Settings and Design : This was a case series analysis using tissue microarray technology. Materials and Methods : Formalin-fixed Paraffin-embedded (FFPE) tissue blocks of histological proven cases of OSCC (n = 30) were retrieved from the department archives. Tissue microarray blocks were constructed; 4 ΅m thick sections were cut and immunostained for p53, Bcl-2 and E-cadherin. Stastistical Analysis : Mean (SD) was used to summarize age, frequencies with percentages was used to summarize categorical variable and Chi-square test was used to find association between histopathology evaluation and expression of Bcl-2, p53, E-cadherin. Results and Conclusion : Bcl-2 was the most frequently expressed biomarker. The expression of Bcl-2 was inversely related to the degree of differentiation (P = 0.005). The follow-up data showed that 63.6% of the cases that were positive for both Bcl-2 and E-cadherin were disease-free following treatment. Tissue microarray technology is a promising way to analyse multiple biomarkers simultaneously. The molecular data obtained from TMA will enhance diagnosis, provide better prognostication and will improve cancer treatment for individual patients.

Background : Up to 10% of patients who develop a nosocomial blood stream infection (BSI) in the hospital have an underlying malignancy. The treatment of infections in patients with malignancy often relies on the use of established guidelines along with the consideration of the local microbiology and antibiotic sensitivity patterns of possible etiologic agents. AIMS: This study attempts to identify the likely etiologic agents and the antibiotic sensitivity profile of BSIs in cancer patients. Settings and Design: This was a retrospective study. Methods and Material: The study was conducted at a tertiary care center for cancer patients, in which samples representing blood stream infections sent from the Medical Oncology services of the hospital during the year of 2007 were analysed. The microbiological profile and antibiotic sensitivity pattern of these isolates was studied. Results: There were 484 isolates that represented BSIs. The most common bacterial isolates from patients with cancer were Pseudomonas spp. (30.37%), Staphylococcus aureus (12.6%) and Acinetobacter spp. (11.57%). Meropenem was the most effective antibiotic with 71.2% sensitivity to the bacterial isolates it was tested against. Oxacillin resistance was seen in 18% of S. aureus isolates. Conclusion: Gram-negative bacteria were more common as etiologic agents of BSIs in cancer patients. The poor activity of the primary empirical agents for infections in cancer namely ceftazidime and piperacillin-tazobactam is alarming.Strict regulation of vancomycin use should be considered in areas where there is a low prevalence of methicillin-resistant S. aureus (MRSA).

Background : Relapse of disease is documented in 15-20% of children with acute lymphoblastic leukemia (ALL). Although testicular relapse is rare with modern risk-adapted treatment protocols, earlier, the testes were a frequently encountered site of relapse and were designated as "drug sanctuaries". Purpose : This descriptive study was designed to assess the pattern of testicular relapse and to identify high-risk factors. Materials and Methods : Data obtained from case records of 407 boys with ALL were analyzed. Fine needle aspiration cytology was carried out in children presenting with painless enlargement of testi(e)s. Bone marrow aspiration and cerebrospinal fluid examination were performed concomitantly to confirm or exclude disease at these sites. Results : Testicular relapse was documented in 30 boys. It was isolated in 17 patients and associated with bone marrow and/or central nervous system relapse in 13. At relapse, nine boys were over the age of 10 years. The majority were very early and early relapsers. Hyperleucocytosis was documented in five of 30 and seven of 137 relapsers and nonrelapsers, respectively (P = 0.04). Twelve of the 30 boys with testicular relapse were treated with testicular irradiation, reinduction and maintenance therapy. The estimated median overall survival was 33 months. Conclusion : Testicular relapse, which depends on the therapy administered, may manifest several months/years after completion of treatment. The high incidence of testicular relapse in our series implicates the need of revaluation of our protocol and incorporation of high/intermediate dose methotrexate therapy upfront.

Introduction: Papillary thyroid cancer (PTC) is the most common well-differentiated cancer of the thyroid and is one of the fastest growing group of cancers probably because of the increased use of ultrasound (HRUSG) in the evaluation of the thyroid in recent years. Materials and Methods: A MEDLINE and OVID database search was performed to collect information on papillary thyroid carcinoma. Recently published consensus guidelines were also used as an additional resource. Conclusions: The controversy regarding the extent of thyroidectomy in patients of PTC is relatively settled, with total thyoidectomy being the preferred approach with nodules >1.5 cm in size. Lymph node (LN) metastases do not seem to affect the overall survival, but they do increase the recurrence rate. It is worthwhile to offer LN dissection at initial surgery if LNs are ultrasonologically diagnosed to harbor malignancy. In experts hands, the rate of recurrent laryngeal nerve injury and hypoparathyroidism is negligible in a neck dissection in initial surgery and remains negligible if carried out in a redo or completion scenario.

Quality of life among young women with breast cancer: Study from a tertiary cancer institute in south IndiaB Dubashi, E Vidhubala, S Cyriac, TG SagarApril-June 2010, 47(2):142-147DOI:10.4103/0019-509X.63005 PMID:20448376

Background : The incidence of breast cancer in young patients less than 35 years is less than 1%. The physical and psychosocial morbidity may affect their ability to successfully function in their social roles. Hence we studied the quality of life (QOL) issues in this subset. Materials and Methods :Younger women with age less than 35 years, diagnosed with non-metastatic breast cancer at our Institute, from 1995 to 2005, were included in the study. Quality of life issues were studied during the follow-up using EORTC QOL C30 and BR23. Descriptive and inferential statistics were used in order to analyze the data. Results : A total of 51 patients were included for the study. The mean age at diagnosis was 30 years. The effect of breast cancer on the occupation and marital status was minimal. The global health status and the functional scores were high, while the overall sexual function was lower. The global health status was higher in the mastectomy group. The arm symptoms (P = 0.027) and pain were higher in the Breast conservation surgery (BCS) group. The sexual symptoms appeared to be higher in the ovary ablated group when compared to the ovary preserved group. The sexual functional scores (P = 0.02) and sexual enjoyment scores (P = 0.003) were better in the mastectomy group. Conclusion : The overall QOL in younger patients with breast cancer appeared to be good. The QOL and sexual function were marginally worse in the breast conservation group when compared to mastectomy group.

Context : Estrogen receptors (ER) and progesterone receptors (PR) play a significant role in the prognosis of breast cancer. For preoperative chemotherapy in locally advanced lesions, trucut biopsy is used to localize the ER and PR receptors by immunohistochemistry. Immunocytochemistry can be a better alternative to immunohistochemistry as it better fixes cells. AIMS : To evaluate the degree of correlation between immunocytochemical (ICC) and immunohistochemical (IHC) determination of ER and PR in breast cancer. Settings and Design : Fine needle aspiration cytology (FNAC) was performed on 100 primary breast cancers immunostained for ER and PR during a period of 1 year 7 months, i.e., from January 2006 to July 2007. Materials and Methods : Papanicolaou-stained slides were destained, fixed in cold acetone and submitted for immunocytochemistry. In the prospective analysis, FNAC smears were straightaway fixed in cold acetone and submitted for ER and PR. Peroxidase, antiperoxidase technique was used for immunocytochemistry. Statistical Analysis : Spearman Rank correlation test was used. Results : Differences between groups were analysed and correlations were studied. Concordance for ER was 50% and for PR was 29%. Both ER and PR were positive in four cases: ER only in three and PR in one, and both were negative in nine cases. Use of the least best buffer and technical errors contributed to the lower ICC rate. Conclusion : Although Immunocytochemistry removes the derogatory step of antigen deterioration, technical errors can cause hindrance in achieving the best of the results.

Context: Cancer profile varies in different regions and depends on race, lifestyle and diet. The study of a cancer profile helps to know the common cancers in a particular population, its probable risk factors and also helps in cancer control programs. AIM: To study the cancer profile at Kolar, based on Pathology Department records. Settings and Design: Retrospective study from January 1997 to December 2006. Materials and Methods: Cancer cases diagnosed by fine needle aspiration cytology (FNAC) and histopathology in the Department of Pathology were included in the study. The relevant history, clinical findings, and sociodemographic information of each case was retrieved from hospital records. Statistical Analysis Used: Descriptive statistics. Results: Out of a total of 19,615 cases reported at the Department of Pathology, 2,744 (13.98%) were cancer cases. The peak incidence was in the fifth decade in females and the seventh decade in males. Male : Female ratio was 0.7 : 1. Overall there was a steady rise in the number of cases from year 1997 to 2006. The top ten cancers in males were of oral cavity, stomach, esophagus, bone, non-Hodgkin's lymphoma (NHL), prostate, liver, larynx, penis, and Hodgkin's disease / bladder and those in females were oral cavity, cervix, breast, stomach, esophagus, thyroid, ovary, bone, rectum, and melanoma. Conclusions: Oral cavity and upper gastrointestinal cancers predominated in both genders. In females, cervical cancer predominated over breast cancer. Thyroid cancers were relatively more common in this region especially in females.

Background : As the tumor spreads through the pathway of least resistance, the present study was carried out to evaluate the presence of perineural infiltration and spread of oral squamous cell carcinoma (OSCC) along the perineural spaces in gingivobuccal sulcus tumors infiltrating into the mandible. AIMS and objectives : (1) To investigate the incidence of perineural invasion of OSCC along the inferior alveolar nerve and (2) to investigate the neurovascular bundle as a potential route of spread of OSCC. Materials and Methods : Twenty-six patients with histopathologically proven OSCC of the gingivobuccal sulcus with radiographic infiltration of the mandible were included. The surgical specimens were decalcified and serially sectioned. Each section was stained with hematoxylin and eosin and was screened for the presence of perineural invasion and spread. Results : Twenty-five specimens showed perineural infiltration but none of the cases showed perineural spread along the inferior alveolar canal. Also, not all cases showed any neurologic deficit. Follow-up of these cases showed early recurrence (6-8 months) in the study group. Conclusion : Perineural infiltration is present in OSCC but perineural spread along the inferior alveolar canal is absent. It is a bad prognostic indicator.

Introduction : Mature T/NK cell lymphomas (MTNKL) presenting as leukemia are rare and show considerable overlapping of clinical, morphological and immunophenotypic features. AIM: Critical analysis of the morphology and immunophenotypic profile of MTNKL. Materials and Methods : We reviewed 380 consecutive cases of mature lymphoid neoplasm that presented as leukemia and were diagnosed on morphology and immunophenotyping of bone marrow and/or peripheral blood samples. Results : Peripheral blood and bone marrow involvement was seen in all cases. MTNKL constituted 4% (nine cases) of all mature lymphoid neoplasms presenting as leukemia. It included four cases of T-large granular leukemia (T-LGL), two of T-cell prolymphocytic leukemia small cell variant (T-PLL), two of adult T-cell leukemia/lymphoma (ATLL) and one of primary cutaneous gamma delta T-cell lymphoma (PCGDTCL). T-LGL revealed CD4-/CD8+ phenotype in three, and CD4+/CD8+ phenotype in one case. CD56 was absent in all the cases of T-LGL. One case of T- PLL small cell variant showed CD4+/CD8- phenotype, while the other revealed CD4-/CD8+ phenotype. Both cases of ATLL showed CD4+/CD8+/CD25+ phenotype. The single case of PCGDTCL showed CD4-/CD8- phenotype pattern. CD3 and CD5 were expressed in all MTNKL. CD7 was absent in three cases of T-LGL. TCRα/β was performed in three cases of T-LGL and was positive in all. TCRα/β was also seen in both the cases of T-PLL small variant. However, TCRα/β was seen in the single case of PCGDTCL. Conclusion : Mature nodal T/NK cell neoplasms are rare and MTNKL presenting as leukemia are even rarer. There is an overlap between the immunophenotypic profiles of different MTNKL subtypes and elaborate T/NK cell panels are required for their evaluation.

Background : After orchiectomy in stage I seminoma the standard is adjuvant radiation therapy. We analyzed the patients retrospectively to evaluate the contributions of the treatment volume and dosage to treatment outcomes. Materials and Methods : Between January 1999 and December 2005, 91 stage I seminoma patients with a median age 36 (range;22-62) applied to our center, who were treated using anterior-posterior parallel opposed fields with linear accelerator or Co60 after orchiectomy. Twenty-five (27.5%) patients received irradiation to the paraaortic and ipsilateral pelvic nodes, and 66 (62.5%) patients only received to paraaortic nodes. Results : With a follow up time of median 57 months (range; 27-104), paraaortic nodes treated group had 4 relapses (6%) - 3 of them pelvic, one of them both pelvic and paraaortic. Both paraaortic and ipsilateral nodes irradiated patients had only one relapse (4%) (P = 0.726). While the 5 year overall survival (OS) is 98.8%, it is 100% in the dog-leg group and 98.4% in the paraaortic group (P = 0.548). Univariate analyses of OS and Disease Free Survival (DFS) showed that there is no statistically significant difference related to factors as age, histologic subgroup, tumor size, rete testis involvement, radiotherapy (RT) fields, dose ranges and the therapy device. Conclusion : Adjuvant RT approach is the preferred for non-compliant low risk patients as well as intermediate and high risk patient in stage I seminoma. 20 Gy/ 10 fractions/ 2 weeks RT is the adequate treatment.

Purpose : Staging of breast tumor has important implications for treatment and prognosis. This study aims at pinpointing the frequency of each stage among familial and nonfamilial breast cancers. Materials and Methods : Ninety-nine Jordanian females diagnosed with familial and nonfamilial breast cancer between 2000 and 2002 were enrolled in this study All breast cancer cases were staged according to the TNM classification into in situ, early invasive, advanced invasive and metastatic. Results : Forty-three cases were familial breast cancer and 56 were nonfamilial. One female breast cancer was diagnosed with ductal carcinoma in situ (DCIS) cancer. Fifty cases were diagnosed in early stages of invasive breast cancer, of which 31 cases were familial, 29 cases were classified as advanced invasive, where 21 cases were nonfamilial and 19 cases were metastatic stage of breast cancer, with 16 nonfamilial cases. Stage 2b was the most common stage of early invasive cases and represented 48% of the early stage of breast cancer. On the other hand, among cases diagnosed with advanced invasive breast cancer, stage 3a was the most common stage and represented 89.6% of the advanced stage. Interestingly, all cases of stage 3a belonged to TNM stages of T2N2M0 and T3N1M0. The tumor size in all cases of Jordanian females diagnosed with advanced invasive breast cancer exceeded 2 cm in size due to selection bias from symptomatic women in our study. Conclusion : The incidence of nonfamilial breast cancer was slightly higher than that of the familial type amongst studied the Jordanian females studied. The early invasive stage of breast cancer was more common in the familial while the advanced invasive and metastatic breast cancer cases were encountered more often in the nonfamilial type. Our study was based on a small sample and symptomatic women. Therefore, more research with larger population samples is needed to confirm this conclusion.

Delay in the diagnosis of esophageal carcinoma: Experience of a single unit from a developing countryD Subasinghe, DN SamarasekeraApril-June 2010, 47(2):151-155DOI:10.4103/0019-509X.63009 PMID:20448378

Objectives : Main objective was to analyze the time delay between the onset of symptoms and the histological diagnosis of esophageal cancer. The subsidiary objective was to analyze the relationship between the time delay and stage of the disease at the time of definitive treatment. Study Design , Setting , and Methods : A prospective analysis of patients with esophageal cancer presenting to a single unit over a period of 24 months was performed. Interval from the onset of symptoms to the histological diagnosis and stage at presentation was analyzed. Results : There were 48 patients (male = 26) with a median age of 59.5 (range 43 - 84) years. First symptom was progressive dysphagia in all patients. Subsidiary symptoms were, weight loss in 83.3% (n = 40), abdominal / chest pain in 10 (20.8%), regurgitation in 14 (29.2%), odynophagia in three (6.2%), abdominal discomfort in two (3%), and dyspepsia in two (3%). The mean delay from the appearance of the first symptoms to the end point was 14.9 weeks (range 3 - 37 weeks). Total delay was due to patient delay in 82%, endoscopy delay in 7%, and delay in histological diagnosis in 11%. Conclusions : As the majority (82%) in our study showed patient delay, a community education program may help in their early presentation to the hospital. However, there is also a notable delay in endoscopy and histology (15%) services, mainly due to a shortage of endoscopy units and qualified histopathologists in the state sector.

Introduction : Cross-sectional imaging has had a significant impact on the management of the sinonasal malignancy. Staging of these lesions has been closely monitored by dependence on computerized tomography (CT) scan and now in small proportion with MRI. The objective of the study was to evaluate the reliability of CT scan in assessing the extensions of the sinonasal mass lesions and their impact on tumor staging. Materials and Methods : All cases of sinonasal lesions were reviewed retrospectively from June 2001 to May 2006 (five years) at KMIO, Bangalore. Only those cases that had CT scan reports and Histopatholgy Examination (HPE) reports were included in the study. All the cases, which were subjected to radiotherapy prior to surgery, were excluded from the study. There were a total of 38 cases with slight male preponderance. Tumor staging was done according to the sixth edition of TNM classification of malignant tumors. Two observers evaluated all the cases (Blinded Study) and sensitivity, specificity, positive predictive value, negative predictive value and predictive accuracy were estimated. Results : The relation between the CT scan findings and HPE reports was high. Though false positivity was noted more in the ethmoid sinuses, significant impact on tumor staging was noted with false positivity of the nasopharynx. Also, false positivity was noted with orbital wall/content extensions, resulting in unnecessary exenterations of the orbit. However, CT scan reliably predicted infratemporal fossa extension in the absence of trismus. False negativity was noted more often in soft palate, indicating the need of using MRI for delineation of tumor extension. Thus, we conclude that judicious use of CT scan in all cases and MRI in selected cases will translate into better tumor-free resections and improves survival.

Aims: To audit the information content of the pathology report on Low Anterior Resection (LAR) specimens and to provide recommendations in order to improve the existing standard of reporting. Materials and Methods : All the reports of LAR specimens during 2004 - 2005 were collected from the Hospital Information System (HIS). Individual items of information were compared with the minimum data sets provided by the Royal College of Pathologists (RCP). Results : Fifty-nine reports were audited. Nineteen percent of the reports were classified as satisfactory. Although many items were well reported, only 30.5% (18/59) of the reports contained a statement on the completeness of excision at the circumferential resected margin and only 25.4% of all reports mentioned the relation of tumors to the peritoneal reflection. Conclusion : The information content of the reports on colorectal cancer resection specimens is inadequate. The use of the standard proforma (template) for reporting rectal cancer is therefore recommended, along with improved education, review of laboratory practices in the light of current knowledge, and further motivation of pathologists through their involvement in multidisciplinary cancer management.

Background : Cell adhesion plays a pivotal role in diverse biological processes that occur in oncogenesis. BRCA1 was the first breast cancer susceptibility gene to be successfully identified and cloned. The role of BRCA1 as a predictive marker of chemotherapy response in breast cancer is proposed. Ligand binding is an important factor in the success of chemoprevention. Materials and Methods : In this work, the author performed a ligand-binding prediction for BRCA1 using a new bioinformatics tool. Results : According to this study, 10 strong possible ligands were identified. Conclusion : These sites can be useful for further drug development studies.